Discharge & Care Coordination Social Worker II

Cape Fear Valley Health System; United States; On-site; USD 65,000 - 85,000; Full time

Job summary

Cape Fear Valley Health System in Fayetteville, NC seeks a dedicated social worker to comprehensively plan services for targeted populations. You will perform psychosocial assessments, crisis intervention, discharge planning, and coordinate referrals to support patients and families across the continuum of care.

You will identify complex cases, review resources, and collaborate with the care team to ensure appropriate social work services, post-acute planning, and patient experience initiatives

Qualifications

• Bachelor’s degree in Social Work is required.
• MSW is preferred for advanced practice and leadership.
• Professional certifications (CSW/CCM/ACM) are preferred.
• Minimum 3 years of experience in Social Services, Home Health, Hospice or Acute Care.
• Acute Care Case Management experience is preferred.

Responsibilities

• Conduct face-to-face interviews to assess psychosocial and discharge needs.
• Perform proactive screenings for clinical, psychosocial, and discharge planning.
• Document assessments, plans, and progress; reassess as needed.
• Initiate referrals and consults for safe, timely discharge/transfer.
• Assist patients and families coping with hospitalization and illness.
• Communicate and advocate with patient, family, and care team.
• Guide patient/family to post-acute care options and resources.
• Coordinate Home Health, Hospice, DME, Rehab, and SNF placements as needed.
• Collaborate with physicians and team to tailor care levels.
• Prepare forms for post-acute placement and coordinate with social services.

Skills

Discharge planning

Psychosocial assessment

Crisis intervention

Communication skills

Advocacy

Education

Bachelor's degree in Social Work

Master's degree in Social Work (MSW)

CSW/ CCM/ ACM certification (preferred)

Tools

Microsoft Office

Midas

ProviderLink

SMS

Job description

Cape Fear Valley Health System in Fayetteville, NC seeks a dedicated social worker to comprehensively plan services for targeted populations. You will perform psychosocial assessments, crisis intervention, discharge planning, and coordinate referrals to support patients and families across the continuum of care.

You will identify complex cases, review resources, and collaborate with the care team to ensure appropriate social work services, post-acute planning, and patient experience initiatives